Visualizing Real-World Pain Treatment Pathways in Chronic Disease: A Sequence-Based Analysis of Polypharmacy in Systemic Lupus Erythematosus.

OBJECTIVE

To examine real-world patterns in pain management among adults with systemic lupus erythematosus (SLE), we focused on the sequencing of pain modalities, polypharmacy, and demographic variation.

METHODS

We conducted a retrospective analysis of electronic health records from adults with SLE treated at a single academic medical center between 2005 and 2024. We included patients who received at least one pain-related therapy, including glucocorticoids, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, anticonvulsants, muscle relaxants, and nonpharmacologic interventions. We used sequence analysis and Sankey diagrams to map treatment trajectories and compared patterns across two periods: 2005 to 2014 and 2015 to 2024. Polypharmacy was defined as receiving five or more pain-related prescriptions within 12 months. We examined trends by age, sex, and race or ethnicity.

RESULTS

Among 769 patients, initiation of glucocorticoids and opioids declined over time (58%-51% and 28%-22%, respectively), whereas NSAID use increased (19%-29%). The median number of pain prescriptions decreased, and polypharmacy prevalence dropped from 53% to 45%. In recent years, younger adults and men received more prescriptions, with 69% of men receiving five or more compared with 43% of women. Racial disparities narrowed overall in recent years but persisted in sensitivity analyses excluding glucocorticoids.

CONCLUSION

Pain management in SLE is shifting away from high-risk therapies; however, prescribing intensity remains high and varies by demographic group. Visualizations serve as a complementary lens to traditional prescription counts, allowing representation of polypharmacy not only by volume but also by the diversity and sequencing of therapeutic classes over time.